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Pharmacy Innovators PodcastTop Opportunities for Healthcare Executives in 2025In this episode of the Pharmacy Innovators Podcast, Visante CEO Steve Rough and President Phil Brummond dive into Visante’s Top Ten Issues Facing Health System Pharmacy in 2025. This insightful discussion covers key topics such as alternative payment models, revenue cycle optimization, centralized medication access, and more—critical areas shaping the future of pharmacy practice. Join them as they explore how to advocate for essential resources, the expanding role of pharmacy services in health system strategy, and major healthcare marketplace changes that could impact your organization. Don’t miss this episode for expert insights and strate...2025-02-1939 minPharmacy Innovators PodcastKey Takeaways from ASHP Midyear: Insights with Dave Hager and Lynn ThomaIn this episode, we’re joined by Dave Hager, Managing Director at Visante, and Lynn Thoma, Senior Director at Visante, as they share their key takeaways from the ASHP Midyear Conference. Dave and Lynn dive into the major themes shaping pharmacy practice, highlight perspectives that challenged or inspired them, and discuss how the conference content aligns with the current trends and challenges facing the industry. Don’t miss this insightful conversation as they break down the conference highlights and share their expert analysis!2024-12-1834 minPharmacy Innovators Podcast340B Policy and Real-life ChallengesThe 340B landscape is constantly evolving, presenting both challenges and opportunities for healthcare providers. Visante is committed to helping organizations navigate the complexities that come with a 340B program. To stay informed, listen to our latest podcast on all things 340B. Our guests, Ted Slafsky, Publisher and CEO of 340B Report, and Kristin Fox-Smith, Senior Vice President at Visante, discuss critical topics such as: The evolving landscape of 340B advocacy The importance of data sharing and transparency The impact of telehealth on patient care The role of audits in program integrity The importance of an effective d...2024-08-2135 minPharmacy Innovators PodcastThe Importance of Work-Life Balance in HealthcareHappy New Year, listeners! The start of the New Year usually comes with self-reflection and new intentions. As we continue to see staffing shortages, escalating workload demands, burnout and silent quitting as significant challenges for hospitals and health systems how do we address these labor concerns? In this episode, we embark on one of the topics that healthcare workers have the most trouble achieving: work-life balance (or should we say LIFE-work balance). Visante Senior Director, Angie Amado, and Visante Senior Consultant, Lynn Thoma, have an honest conversation with our host, Jim Jorgenson, about the importance of work-life...2024-01-1729 minPharmacy Innovators PodcastThe infusion market is evolving. Are you ready? It’s a familiar theme in healthcare: the movement of traditional acute care to a variety of ambulatory settings. Infusion therapy is one of the fastest-growing examples of this transition, and the market continues to shift as a result of this strong growth. In this episode of our Visante Innovators podcast, we take a deeper look at what’s driving the expansion of the infusion market. Join Visante CEO Jim Jorgenson, University of Maryland Director of Home Infusion Services Chris White, and Visante Senior Director Erick Siegenthaler as they discuss infusion changes and challenges, plus how health systems should be t...2023-08-1640 min
Pharmacy Revenue Cycle PodcastThe Heavy Hitters for July Quarterly UpdatesJuly 2023 is here and time to validate another round of quarterly updates from CMS. The JZ modifier, in addition to the JW modifier, is now required to effectively bill for drug waste (JW) and to attest when no drug was discarded (JZ) for all separately payable that are single-dose or single-use containers. Additionally, we have updated the Visante Quarterly Update Tool and the C9399 Tool to help organizations validate that their system is up to date with the recent changes. 2023-07-0604 minPharmacy Innovators PodcastIt’s a Crisis: The Pharmacy Technician ShortageHealth systems have been plagued by shortages of pharmacy technicians and many fear it will continue to get worse. Rico Powell, Senior Consultant at Visante and Managing Partner at Professional Pharmacy Technician Academy, joins our host, Jim Jorgenson, to discuss the pharmacy technician crisis. In this episode, Rico highlights technicians’ role in medication safety and what pharmacy leaders can do to help mitigate the high turnover. Professional Pharmacy Technician Academy: www.pptaacademy.com Contact Rico Powell: rpowell@pptaacademy.com White Paper: The Pharmacy Technician Workforce Crisis Tra...2023-06-2116 minPharmacy Innovators Podcast340B Program Pressures Intensify: Who Will Fund Indigent Care?Maria Kossilos, Assoc. Chief Pharmacy Officer at Cambridge Health Alliance, joins Kristin Fox-Smith (340B ACE), Managing Director at Visante, to discuss how pharmaceutical manufacturer restrictions – some as recent as last week – put enormous financial pressure on health systems and covered entities who are doing what they can to care for vulnerable and underserved patients across America. Kossilos and Fox-Smith describe why the 340B outlook is somewhat bleak, as the fear of continuing to lose 340B savings could well become a reality in the coming 18-24 months. However, they also describe real solutions such as utilizing 340B ESP in wa...2023-05-1726 min
Pharmacy Revenue Cycle PodcastHospital Outpatient Prospective Payment System (OPPS) Final Rule- CY2023The Centers for Medicare & Medicaid Services (CMS) provided the OPPS Final Rule for CY2023 in the Federal Register on November 23, 2022. Provisions in this rule will be effective for dates of service on or after January 1, 2023. Significant changes for drug reimbursement and coding occur in three areas: 340B-acquired drugs, non-opioid pain management reimbursement in Ambulatory Surgery Centers (ASC) and Hospital Outpatient Departments (HOPD), and new requirements for reporting waste in HOPD. 340B-acquired Drugs In light of the Supreme Court decision in American Hospital Association v. Becerra, 142 S. Ct. 1896 (2022), CMS is applying the default rate...2022-12-2204 minPharmacy Revenue Cycle PodcastDrug Waste is Packed with a Punch and a RefundDive into the CY23 CMS Physician Fee Schedule rule as it relates to the new requirements for discarded drugs or drug waste. A JW and JZ modifier are required for all Part B separately payable single-dose or single-use packages. Additionally, manufacturers are required to pay a refund for discarded drugs that exceed 10% of the total charges. 2022-12-0808 minPharmacy Innovators PodcastVisante Pharmacy Automation Series - Part 4In this episode of the pharmacy innovators podcast we have Ghalib Abbasi and Gee Mathen. These two innovators are making major breakthroughs in pharmacy automation and making it safer for patients! Let's see how they're doing that...2022-11-1733 minPharmacy Revenue Cycle PodcastPayment Increases for BiosimilarsPayment Increases for Biosimilars On April 16th, 2022, the Inflation Reduction Act of 2022 was signed into law. Section 11403 requires a temporary increase in add-on payment for qualifying biosimilars from 6% to 8% for 5 years. This change was implemented on October 1, 2022, and CMS uploaded pricing files that already include the temporary price increase. Applicable 5-year period This increase began on October 1, 2022, for products for which payment was made by September 30, 2022. For other biosimilar products in which payment was made between October 1, 2022 - December 31, 2027, the 5-year period will begin on the first day of such a calendar quarter in...2022-11-1504 min
Pharmacy Innovators PodcastVisante Pharmacy Automation Series - Part 3In part 3 of our series on automation, we're going to be talking about the optimization of the automation solution that has been selected.2022-11-1023 minPharmacy Innovators PodcastVisante Pharmacy Automation Series - Part 2In the first of our series on pharmacy automation we talked about initial planning...now, we discuss implementation!2022-11-0323 minPharmacy Revenue Cycle PodcastCar T-cell Therapy: Coverage and Billing-Outpatient (Updated – October 1, 2022)Chimeric Antigen Receptor (CAR) T-cell therapy is an example of a rapidly emerging immunotherapy approach called adoptive cell transfer (ACT) where patients’ own immune cells are collected and used to treat their cancer. This newsletter details coverage and billing instructions when the products are used on an outpatient basis and has been updated to reflect HCPCS codes current as of October 1, 2022. The Center for Biologics Evaluation and Research (CBER) of the Food and Drug Administration (FDA) regulates cellular therapy products, human gene therapy products, and certain devices related to cell and gene therapy. The FDA pro...2022-11-0104 minPharmacy Innovators PodcastVisante Pharmacy Automation Series - Part 1In the first of four parts of our series on Pharmacy Automation Projects, we're going to discuss what goes into initial planning.2022-10-2722 minPharmacy Revenue Cycle PodcastVacating the 340B Payment Reduction PolicyOn September 28, 2022, the US District Court issued a ruling that states the Department of Health and Human Services (HHS) is required to vacate the prospective portion of the 340B reimbursement rate outlined in the 2022 Outpatient Prospective Payment System (OPPS) Rule. In other words, payment rates must revert to the default of ASP + 6% rather than the reduced rate for select drugs of ASP - 22.5%. The decision was determined to not cause substantial disruption; thereby, requiring HHS to begin immediately. This was in response to American Hospital Association v. Becerra, 142 S. Ct. 1896 (2022), in which the Supreme Court ruled against the Department...2022-10-1904 minPharmacy Revenue Cycle PodcastFY23 New Technology Add-On Payment for Inpatient ReimbursementThe FY2023 Inpatient Prospective Payment System (IPPS) Final Rule was published in the Federal Register and is effective October 1, 2022. NTAP is considered for new services or technologies when: 1) they are new and not substantially similar to other existing services or technology; 2) the services or technology is more costly or the MS-DRG payment is inadequate for coverage of the new technology; 3) the service or technology demonstrates substantial clinical improvements over existing services or technology with the exception of certain antimicrobials which have been approved under the Limited Population Pathway for A...2022-10-0405 minPharmacy Revenue Cycle PodcastBack to Flu SeasonIt’s that time of year again when school supplies are purchased and vaccines are updated. Influenza vaccines continue to challenge organizations to ensure each NDC, CVX code and HCPCS code are appropriately mapped in EMRs. We simplify this process with an Influenza Vaccine Billing Tool that can be found on our webpage Pharmacy Revenue Cycle | Visante. Shout Outs! Pharmacy and revenue integrity teams ensure the new NDCs are updated for accurate billing. Pharmacy and revenue integrity teams revalidate Sanofi Pasteur's high dose formulation at 0.7 mL versus the traditional 0.5 mL. CPT code 90662 will be used to code...2022-09-2004 minPharmacy Revenue Cycle PodcastComment Letter on IPPS FY2023 Proposed Rule and NDC Reporting for NTAP DrugsDear Readers:Below is the content from a letter we submitted to CMS regarding their proposal in the IPPS FY2023 Proposed Rule to discontinue ICD-10-PCS codes for identifying drugs eligible for NTAP and switch to requiring NDC numbers be reported on inpatient. We’ve made an alternate suggestion after talking with many of you, and also offered some important steps that should be taken to ensure the integrity of the data if CMS proceeds with this proposal. Please send us your feedback. We’ll do another analysis when the Final Rule is issued in Augus...2022-07-1903 minPharmacy Revenue Cycle PodcastCar T-cell Therapy: Coverage and Billing-Outpatient (Updated-July 1 2022)Chimeric Antigen Receptor (CAR) T-cell therapy is an example of a rapidly emerging immunotherapy approach called adoptive cell transfer (ACT) where patients’ own immune cells are collected and used to treat their cancer. This newsletter details coverage and billing instructions when the products are used on an outpatient basis and has been updated to reflect HCPCS codes current as of July 1, 2022. The Center for Biologics Evaluation and Research (CBER) of the Food and Drug Administration (FDA) regulates cellular therapy products, human gene therapy products, and certain devices related to cell and gene...2022-06-3004 minPharmacy Revenue Cycle PodcastWhat's New? Using HCPCS Code C9399 (7/1/2022 Update)What’s NEW? Using HCPCS Code C9399 (July 1, 2022 update) HCPCS code C9399-Unclassifed drugs or biologicals, can be used to bill for new drugs, biologicals, and therapeutic radiopharmaceuticals that are approved by the FDA on or after January 1, 2004 when a product-specific HCPCS code has not yet been assigned when furnished in hospital outpatient departments. (Medicare Claims Processing Manual, pg 63). This C9399 tool includes the generic and brand names, approval dates, manufacturer, and a link to the prescribing information (PI). () for injectable drugs that have been approved by the FDA but have not been ass...2022-06-1606 min
Drug Diversion Insights with Terri VidalsThe Drug Diversion Triad with Maureen Burger, Chief Nursing Officer at VisanteThe Drug Diversion Triad with Maureen Burger, Chief Nursing Officer at Visante
The Drug Diversion Triad gives us a better look at the elements that should be considered when assessing for diversion risk. Facilities can use this information to examine areas where they can have some control and maximize the opportunities for intervention. Listen in as two experienced diversion specialists discuss the triad and share their insights.
For more information, visit www.rxpert.solutions
#opioidcrisis #hospitalworker #drugdiversion #hospitalpharmacy2022-04-1229 minPharmacy Revenue Cycle PodcastCar T-cell Therapy-Billing and Coverage for Outpatients (Updated) Chimeric Antigen Receptor (CAR) T-cell therapy is an example of a rapidly emerging immunotherapy approach called adoptive cell transfer (ACT) where patients’ own immune cells are collected and used to treat their cancer. This newsletter details coverage and billing instructions when the products are used on an outpatient basis and has been updated to reflect HCPCS codes current as of April 1, 2022. The Center for Biologics Evaluation and Research (CBER) of the Food and Drug Administration (FDA) regulates cellular therapy products, human gene therapy products, and certain devices related to cell and gene...2022-03-1504 minPharmacy Revenue Cycle PodcastIf All Else Fails, Submit and AppealIt may seem like a scary or intimidating endeavor, but many pharmacy related denials can be overturned when following the appeal process. Medicare has five levels of appeals beginning with a redetermination by the MAC to Judicial Review in the Federal District Court. Before beginning the appeals process, it is prudent to ensure that the claim was coded and billed accurately. Claims that have an error in billing may be corrected by re-submitting utilizing the corrected claim process. Additionally, it is important to understand the reason for the initial denial and ensure there is clinical justification or other supporting...2022-03-0105 minPharmacy Revenue Cycle PodcastConvalescent Plasma: New HCPCS Code for OutpatientsOn December 28, 2021, the FDA revised the emergency use authorization (EUA) for COVID-19 convalescent plasma with high titers of anti-SARS-CoV-2 antibodies. It is now authorized in both the inpatient and outpatient setting for patient with immunosuppressive disease or getting immunosuppressive treatment. On February 10, 2022, CMS issued a new HCPCS code, C9507-Fresh frozen plasma, high titer COVID-19 convalescent, frozen within 8 hours of collection, each unit, billable for dates of service on or after December 28, 2021. The CMS payment rate for C9507 is $750.50. Pharmacies may not purchase or dispense the product but may be involved in...2022-02-1504 minPharmacy Revenue Cycle PodcastNotice: Read All About an ABNPharmacy teams are increasingly embedding themselves within revenue cycle teams and prior authorization processes within infusion and cancer centers as well as other outpatient departments. As this occurs the term ABN may increasingly become an important factor that pharmacy teams otherwise would not originally have dealt with. Or, maybe you as a Medicare beneficiary have wondered what they are and their importance. Advance Beneficiary Notice of Noncoverage or ABN is a written notice given to Medicare fee-for-service or original Medicare beneficiaries to convey that the item or service may not be covered by Medicare Part B s...2022-02-0104 minPharmacy Revenue Cycle PodcastAduhelm and Medicare CoverageOn January 11, 2022, CMS released a proposed National Coverage Determination (NCD) decision memorandum which would cover monoclonal antibodies that target amyloid for the treatment of Alzheimer’s disease through coverage with evidence development (CED). This means that FDA-approved drugs in this class would be covered for people with Medicare only if they are enrolled in a qualifying clinical trial and it must be administered in a hospital outpatient setting. The proposed NCD is open to public comment and comments can be submitted until February 10, 2022 at the NCD database for CAG-00460N: https://www.cms.gov/medicare-coverage-database/view/nca.aspx?ncaid=305&bc...2022-01-2503 minPharmacy Revenue Cycle PodcastCovid Tidal Wave and Remdesivir Changes Many of you may be experiencing another tidal wave of surges with the Omicron Covid-19 variant. Though we have been fighting the pandemic for almost two years, each surge seems to bring new battles. The NIH recently published new outpatient therapy guidelines to help combat the Omicron variant; as well as, we have received a few questions from our readers on how to handle the billing changes. Remdesivir is now among one of the treatment options for non-hospitalized patients when Omicron is the predominant circulating variant. CMS has designated HCPCS code J0248, injection remdesivir, 1 mg. Th...2022-01-1804 minPharmacy Revenue Cycle PodcastPegfilgrastim: Dose Change with New HCPCS Code January is always the biggest quarterly update for HCPCS codes and 2022 is no exception. Some changes are routine with new codes replacing temporary codes and new codes for newly marketed products. One HCPCS code change caught our attention: Pegfilgrastim. Since January 1, 2004, pegfilgrastim has been billed with HCPCS code J2505-Injection, pegfilgrastim, 6 mg. It is curious that when the biosimilars for pegfilgrastim were introduced in June 2018, the products were all assigned brand-specific HCPCS codes with a dose description of 0.5 mg. CMS has now gotten the c...2022-01-1103 minPharmacy Revenue Cycle PodcastSequestration Suspension Extended: Impact on Drug Reimbursement Pharmacy departments may periodically be asked to compare drug payment with cost, particularly when expensive drugs are utilized on outpatients. It is also important to calculate anticipated revenue when preparing annual budgets. The ASP (Average Sales Price) file is published by CMS each quarter and can be used to verify payment for Medicare outpatients or commercial contracts which pay based upon Medicare payment. It sounds straightforward, but there is a catch: “sequestration”. Sequestration is the automatic reduction of federal spending originally established by Congress in the Balanced Budget and Emergency Deficit Contro...2022-01-0406 minPharmacy Revenue Cycle PodcastConnecting the Dots: Pharmacy Involvement in Revenue Cycle It may seem like unnecessary work to review the items on our Quarterly Checklist each quarter to identify changes and updates. Some tasks may be delegated to other groups such as Chargemaster Managers or Billers, but for one task, pharmacy is the best department to “connect the dots”: Restated Payment Rates. Our “action to take” recommendation is: “Map restated payments to the effective quarter, determine impact, and rebill as necessary.” We believe that the pharmacy department is in the best position to take this action and in some cases, increase pharmacy revenue. Let’s walk through an example in more...2021-12-2805 minPharmacy Revenue Cycle PodcastEnd of Year Checklist for New CodesThe end of year brings joy and happiness, but it can also be a very busy time for the revenue cycle and finance teams conducting year end closes. Our goal is to keep the information simple and are here to remind you of our Quarterly Update Tool. CMS has published the majority of files for you to start reviewing changes effective January 1, 2022. The Quarterly Update Tool highlights where the information is located that will be published by CMS. Followed by a column “Action to Take'' that describes how and what to evaluate with each published file. CMS pub...2021-12-2102 minPharmacy Innovators PodcastPharmacy UnscriptedOn the first episode of Pharmacy Unscripted we welcome CEO of Visante, James Jorgenson. James is a pharmacy leader with over 30 years of experience in hospital management and leadership. 2021-12-1930 minPharmacy Revenue Cycle PodcastEverything's made up and the points don't matter. The points are like setting hospital drug charges.Have you ever thought the pharmacy charge structure could have been an intro to the Drew Carey Whose Line Is It Anyway? Well, that may be what most people think, but with the new price transparency regulations that are being pushed forward, understanding how the drug charges are set and optimizing the charge structure is more important now than ever. CMS cannot dictate how much a provider charges, which leaves little guidance for hospitals. This edition will walk through at high level some strategies to consider when establishing the pharmacy markup structures. First and foremost! Ch...2021-12-1405 minPharmacy Revenue Cycle PodcastDietary Supplements: Billing Pitfalls to AvoidHospital pharmacies often carry and dispense dietary supplements and herbal products in order to maintain a patient on their home regimens. Pharmacies may determine which dietary supplements and herbal products they carry based upon patient needs and internal policies, but they can’t be billed as a drug. What does that mean? Just like medical devices, dietary supplements and herbal products may be supplied by the pharmacy, but it is important that they NOT be billed as a drug as only drugs and biologicals are billed with revenue codes 25x (250-259) and 63x (631-63...2021-12-0605 minPharmacy Revenue Cycle PodcastThe Basics of Critical Access Hospitals (CAHs)A reader inquired about Critical Access Hospitals (CAH), so we have put together a few items that pertain to the intricacies of CAHs and how they differ from the Hospital Outpatient/Inpatient Departments. CAH are located in rural areas of a State that has established a Medicare rural hospital flexibility program, or located in a Metropolitan Statistical Area (MSA) that is treated as being located in a rural area based on law or regulation of the State. It is required to be more than a 35-mile drive from any other hospital or “necessary provider”. If located...2021-11-2904 minPharmacy Revenue Cycle PodcastTop 5 Newsletters and NEWSPharmacy Revenue Cycle News has brought you 61 tips to increase your pharmacy revenue since it was launched in September 2020. Since then, we’ve had over 13,000 visits to our website with 278 subscribers! Thank you to our loyal subscribers! Our website is also a repository for regulatory information including billing and compliance information for hospitals, ambulatory surgery centers and physician offices. You can search the entire website here: https://www.pharmacyrevenuecycle.com/search-and-index. We’ve learned that some newsletters are more widely read than others. Our Top 5 newsletters of all time are: Don’t Let Rabi...2021-11-2203 minPharmacy Revenue Cycle PodcastMedical Devices: Billing Pitfalls to AvoidHospital pharmacies often carry and dispense medical devices in order to administer medications, or as part of a package for operating room cases. Pharmacies may determine which medical devices they carry based upon patient needs, but they can’t be billed as a drug. What does that mean? The National Uniform Billing Committee (NUBC) was formed in 1975 to develop and maintain a single billing form and standard data set to be used nationwide by institutional, private and public providers and payers for handling health care claims. Therefore, the Committee is responsible for establishing reve...2021-11-1505 minPharmacy Revenue Cycle PodcastOPPS Final Rule Summary CY2022The Centers for Medicare & Medicaid Services (CMS) provided the Final Rule for CY2022 for the OPPS on November 2, 2021 as a display copy. This document was published in the Federal Register on 11/16/2021 and will be effective for dates of service on or after January 1, 2022. (Links below and page numbers have been updated to reflect the Federal Register version). The good news is there aren’t major changes for drug reimbursement. We’ve recapped the majority of the drug-related issues here. Claims Data- Typically claims data from 2020 would be analyzed for determining payment starting...2021-11-0805 minPharmacy Revenue Cycle PodcastWhat about C Codes?Drugs and biologicals are generally labeled with JXXXX series HCPCS, but there are a growing number of QXXXX, AXXXX, and now CXXXX. The C codes have generated some confusion and are a pain point in maintaining the CDM. But what makes a C code different when it comes to the pharmacy revenue cycle? To start with a little history, C codes were created as a way to implement Section 201 of the Balanced Budget Refinement Act (BBRA) of 1999 or “pass through” payment. The C codes represented items that qualified for payment under the Outpatient Prospective Payment System (OPPS). Prima...2021-11-0104 minPharmacy Revenue Cycle PodcastNDC Numbers: Medicaid Program DataCMS requires all State Medicaid Programs to require National Drug Code (NDC) numbers on “physician-administered” drugs which include those administered in hospital outpatient departments and physician offices. Since Medicaid programs are jointly funded with CMS, this requirement applies to drugs which are covered under Medicare Part B. The program requires a drug manufacturer to enter into a national rebate agreements with the Secretary of the Department of Health and Human Services (HHS) in exchange for the State Medicaid program providing coverage for most of the manufacturer’s drugs. The manufacturer has to electronically submit product and pri...2021-10-2505 minPharmacy Revenue Cycle PodcastPreventative VaccinesInfluenza, pneumococcal, and hepatitis B (intermediate or high risk, 50.4.4.2) may all be preventative vaccines, but the vaccine and its administration are covered 100% by Medicare Part B regardless of where the service is furnished. This includes coverage under Part B when administered to an inpatient during a hospital stay covered under Medicare Part A. We call this out and dedicate this newsletter for two main reasons: Medicare only covers select preventative services. Traditionally, immunizations are only covered when used for treatment of an injury or direct exposure, such as rabies vaccine (see previous newsletter). ...2021-10-1804 minPharmacy Revenue Cycle PodcastCetuximab MUE increased to 150 unitsIn our July 12, 2021 Newsletter, we reported that a new regimen was approved by the FDA for Cetuximab that exceeded the current Medically Unlikely Edits. We wrote a letter to CMS asking that it be raised from 120 units to 150 units and the new October 1 MUE tables reflect the increase!!! Facilities who had removed any additional units that exceeded the MUE should evaluate whether re-billing would be appropriate. If the claims are re-billed with the higher units and dates of service prior to October 1, 2021, we recommend submitting a paper claim with medical record documentation that the drug regimen was...2021-10-1101 minPharmacy Revenue Cycle PodcastQuarterly Update Checklist Tool“Teach a man to fish, and you’ve fed him for a lifetime” is a popular quote. Pharmacy Revenue Cycle News reviewed the July 1, 2021 updates for you, and now has published a new tool for your organization to breakdown the quarterly updates published by CMS. The tool can be found here or go to pharmacyrevenuecycle.com > Resource Files > Tools. The Quarterly Update Tool highlights where the information is located that will be published by CMS, followed by a column “Action to Take'' that describes how and what to evaluate with each published file. CMS publishes this inform...2021-10-0403 minPharmacy Revenue Cycle PodcastNTAP FY2022The FY2022 Inpatient Prospective Payment System (IPPS) Final Rule was published in the Federal Register and is effective October 1, 2021. Of which, the New Technology Add-on Payments (NTAP) are a big aspect and impact the Pharmacy Revenue Cycle. NTAP is considered for new services or technologies when: 1) they are new and not substantially similar to other existing services or technology; 2) the services or technology is more costly or the MS-DRG payment is inadequate for coverage of the new technology; 3) and the service or technology demonstrates substantial clinical improvements over existing services or technology with the exception of cer...2021-09-2705 minPharmacy Revenue Cycle PodcastHappy Birthday Pharmacy Revenue Cycle NewsWe started Pharmacy Revenue Cycle News in September 2020 to take complex billing and coding information for drugs and make it more simple. We’ve provided a weekly newsletter and podcast and our website is a repository for tools that combine information from multiple sources. As we head into our second year, we want to thank YOU, our READERS. Your thoughtful questions and encouragement have made our newsletters more useful as you’ve helped us to identify important, late-breaking topics, or areas of drug billing that have always been a little murky. For our...2021-09-2103 minPharmacy Revenue Cycle PodcastCAR T-cell Therapy: Coverage and Billing for OutpatientsChimeric Antigen Receptor (CAR) T-cell therapy is an example of a rapidly emerging immunotherapy approach called adoptive cell transfer (ACT) where patients’ own immune cells are collected and used to treat their cancer. Accurate billing for these products and the associated services is extremely important due to the cost and clinical resource intensity of administering the products. We previously provided instructions for the billing of CAR T-cell therapies when provided to an outpatient. This newsletter provides billing and reimbursement information when these products are administered to hospital inpatients. The Center for Biolo...2021-09-1310 minPharmacy Revenue Cycle PodcastTocilizumab for Inpatient Covid-19 inpatients How do you bill an outpatient monoclonal antibody used in a hospitalized Covid-19 patient in which the facility incurs a cost? This seems to be one of many riddles to solve as we continue to fight the Covid-19 pandemic. Tocilizumab under the EUA is approved for hospitalized patients > 2 years of age receiving corticosteroids and requiring supplemental oxygen. CMS issued its separate HCPCS, Q0249, from that of the original HCPCS, J3262 used when given for FDA approved indications. Similar to the vaccines, there are two separate HCPCS codes for the 1st administration (M0249) and 2nd administration (M0250). However, u...2021-09-0706 minPharmacy Revenue Cycle PodcastBilling Tocilizumab and AlternativesDelta variant is creating some commotion to say the least. Tocilizumab (Actemra) used to treat rheumatoid arthritis among other things is now being used to treat hospitalized patients with Covid-19 under an EUA. The storm has created a world wide shortage leaving organizations up to their own devices to battle hospitalized Covid-19 patients and patients who were actively being treated with tocilizumab for other indications. While you focus on treating patients, we are here to help iron out the billing implications whichever method you choose. While we do not provide recommendations for clinical alternatives, here are some t...2021-09-0304 minPharmacy Revenue Cycle PodcastWhy Should I Report Every Drug Separately? Extra Money?We often hear, “We don’t bill the contrast material separately. We know it’s a drug, but we include the cost in the charge for the procedure so we don’t have to keep updating the drug files” or “We only report HCPCS-coded drugs separately since we don’t get paid for the rest.” There are good reasons to report ALL Drugs, biologicals and radiopharmaceuticals separately on claims: CMS requires all separately payable drugs to be reported separately CMS requests all drugs be reported separately so that they can properly allocate packaged...2021-08-3008 minPharmacy Revenue Cycle PodcastMFN Model Rule-Proposal to RescindCMS has issued a proposed rule to rescind the Most Favored Nation (MFN) interim final rule that appeared in the Federal Register on November 27, 2020. There will be a 60 day comment period regarding this proposal to rescind the MFN interim final rule with comments due to CMS by October 12, 2021. The MFN was a 7-year nationwide mandatory model that would phase out the ASP methodology to determine Part B drug payment for a select number of high cost drugs. Rather, it was designed to align payment for Part B drugs to that of the lowest purchase cost fr...2021-08-2303 minPharmacy Revenue Cycle PodcastCMS issues billing codes for 3rd dose of Pfizer and Moderna COVID-19 vaccineOn August 16, 2021, CMS issued a special bulletin: Effective August 12, 2021, CMS will pay to administer additional doses of COVID-19 vaccines consistent with the FDA EUAs, using CPT code 0003A for the Pfizer vaccine and CPT code 0013A for the Moderna vaccine. A table of all current COVID-19 vaccines and monoclonal antibody codes is available at this link. CMS will pay the same amount to administer this additional dose as they did for other doses of the COVID-19 vaccine (approximately $40 each (subject to site of care and geographic adjustments)). CMS continues to make it clear to private i...2021-08-1704 minPharmacy Revenue Cycle PodcastChemotherapy Administration Codes-Change in Billing InstructionsThe American Medical Association (AMA) is responsible for the maintenance of the Current Procedural Terminology (CPT) codes. Drug administration services are reported with CPT codes in the range 96360-96379 for Hydration, Therapeutic, Prophylactic, and Diagnostic Injections and Infusions, and range 96401-96549 for Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration. Drug Administration services codes are typically billed on outpatient claims. The CPT manual provides guidance on when the higher-reimbursed “Chemotherapy/Highly Complex” codes can be used which includes non-radionuclide anti-neoplastic agents, anti-neoplastic agents provided for noncancer diagnoses or substances such as certa...2021-08-0906 minPharmacy Revenue Cycle PodcastBack to Flu SeasonIt’s that time of year again when school supplies are purchased and flu shots are given. A silver lining of the Covid-19 pandemic, flu transmission was relatively low in the 2020-2021 season but it is unknown what is in store for 2021-2022 season. Each year seems to be a new experience and a new scurry to aggregate the new NDC data to update EMRs. For the second year, we have simplified this process by creating a NDC to billing crosswalk! The Influenza Tool for 2021-2022 can be found on our website PharmacyRevenueCycle.com. This crosswalk contains the...2021-08-0303 minPharmacy Revenue Cycle PodcastWhat, No Changes? OPPS CY2022 Proposed Rule SummaryThe Centers for Medicare & Medicaid Services (CMS) provided the Proposed Rule for CY2022 for the OPPS System on July 20, 2021. This document is scheduled to be published in the Federal Register on 08/04/2021. Comments are due to CMS on September 17, 2021. The good news is there aren’t major changes for drug reimbursement. We’ve recapped the majority of the drug-related issues here. 1. Claims Data- Typically claims data from 2020 would be analyzed for determining payment starting January 1, 2022. However, due to the pandemic, CMS is exercising its authority and will use data from 2019 claims similar to what was proposed in the Inp...2021-07-2605 minPharmacy Revenue Cycle PodcastASP Calculations and Self-Administered DrugsDid you notice the decrease in payment rate in abatacept and certolizumab in the July 2021 quarterly update? They decreased by 22% and 19% respectively, but did you dive into the details? Changes in payment rates are difficult to track and understand their correlation with the ASP value and the price in which your organization may pay for the drug. ASP values are calculated based on submission of sales price net any price concessions (e.g. volume discounts, prompt pay, cash discounts) by the manufacturer during the quarter and generally have a two quarter lag. Manufacturers submit the information by NDC, and CMS t...2021-07-2005 minPharmacy Revenue Cycle PodcastTake-Home Meds: To Bill or Not to BillThe past few years have seen an increase in “Take-Home Meds” Programs. There are specific billing rules that apply to Medicare patients with Part A, B and/or D coverage who opt to receive “Take-Home Meds”. Inpatients If only a limited supply is needed to cover the time from discharge until an inpatient can get a prescription filled in a network pharmacy, hospitals are permitted to dispense a limited supply and include it in the Part A (inpatient) claim (and not bill Medicare Part D or the patient). Chapter 1, Section 30.5 Drugs For Use Ou...2021-07-1204 minPharmacy Revenue Cycle PodcastCetuximab (ERBITUX): New Dosing Regimen exceeds MUE valueWe’ve previously written about Medically Unlikely Edits (MUE) published by CMS and how to appeal them on an individual patient case basis. This article also pertains to MUE values but outlines a different process to ensure that clinically appropriate drugs are reimbursed for Medicare outpatients and uses a new dosing regimen for Cetuximab (Erbitux®) as an example. Background Cetuximab is a chemotherapy agent approved for patients with K-Ras wild-type, epidermal growth factor receptor (EGFR)-expressing, metastatic colorectal cancer (mCRC) or squamous cell carcinoma of the head and neck (SCCHN). On...2021-07-0505 minPharmacy Revenue Cycle PodcastJuly 2021 CMS Quarterly Updates In order to foster innovation and expedite adoption of and patient access to new medical technologies, CMS has implemented a quarterly HCPCS code application opportunity for drugs and biological products while other procedures are on a bi-annual application opportunity. Quarter 3, 2021 is packed with a bang and we have evaluated the key elements and a process for breaking down drugs and biologicals. There are a couple places in which you can find this information including the published transmittal (1082) and MLN matters (MM12316) which provide the information in a narrative form and by going to the tables directly and extracting from...2021-06-2807 minPharmacy Revenue Cycle PodcastRevenue CodesThe National Uniform Billing Committee (NUBC) was formally organized in May 1975 and develops and maintains the UB-04 (uniform billing) data set used by the institutional health care community. The NUBC is one of four organizations recognized in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) for a special consultative role around the development and adoption of administrative transactions for the electronic exchange of health information. One of the primary responsibilities of the NUBC is to maintain and update the revenue codes used by institutional providers for billing. Revenue codes are not used on physician cl...2021-06-2107 minPharmacy Revenue Cycle PodcastCOVID Infusion Confusion The monoclonal antibody infusions may seem like old news at this point, especially as mask restrictions loosen and Covid-19 fears decrease. However, healthcare workers continue to battle the Covid-19 and utilize the monoclonal antibodies under the FDA Emergency Use Authorization (EUA). In a previous Pharmacy Revenue Cycle Newsletter, we outlined information required to bill these monoclonal antibodies as they are approved by the FDA EUA. While the monoclonal antibodies are provided free of charge, each organization may be faced with decisions on how to operationalize the medication use process. Typical combination products are manufactured as a s...2021-06-1306 minPharmacy Revenue Cycle PodcastWhen is a Unit not a Unit? Well, a unit is not a unit when you are measuring human plasma-derived blood factors that are used to treat both Hemophilia A and Von Willebrand disease (VWD). Alphanate®, Humate-P®, and Wilate® are all approved to treat both clotting disorders, but the dosing is different. Clinicians use the labeled Factor VIII amount to calculate dosing regimens in Hemophilia A, but use the Von Willebrand Factor/Ristocetin Cofactor (VWF:RCo) amount per vial when treating Von Willebrand Disease. Let’s compare these three products including the HCPCS codes as well as current Part B reimbursement from Addendum B (ef...2021-06-0704 minPharmacy Revenue Cycle Podcast340B Medicare Modifiers The interdisciplinary team collaboration between financial/revenue cycle team members and operations is increasingly important. The implementation of the Medicare billing modifiers and payment implications on 340B purchased drugs highlighted this need for many organizations. Beginning January 1, 2018 CMS Outpatient Prospective Payment (OPPS) finalized payment reductions and billing modifier requirements for select entities who purchase drugs under the federal 340B pricing program and furnish to Medicare beneficiaries by a hospital who are paid under the OPPS. The organization is required to bill each drug line with the appropriate modifier to ensure proper payment. Modifier “JG” D...2021-06-0107 minPharmacy Revenue Cycle PodcastPayment for Hemophilia Factors: Inpatient and Outpatient In recent newsletters, we’ve outlined some scenarios where drugs used on inpatients receive extra payment in addition to the MS-DRG reimbursement. Two examples are for hemophilia factors and drugs designated for 2-3 years of new technology add-on payments. However, some drugs receive separate payment because the inpatient claim is coded differently and results in a higher-reimbursed MS-DRG. Let’s look at the scenario when tPA is administered to a stroke patient in the Emergency Department and then the patient is admitted. Although the tPA may be administered in the ED when the patient still has...2021-05-2405 minPharmacy Revenue Cycle PodcastPayment for Hemophilia Factors: Inpatient and OutpatientCoverage Inpatient The Social Security Act (Section 1886(a)(4)) provides that hospitals receive extra payment for the costs of administering blood-clotting factor to Medicare hemophiliacs when they are hospital inpatients. Payment is based upon a price per unit of clotting factor multiplied by the units provided. Medicare provides coverage for these factor products through Part A (inpatient) and B coverage (‘incident to’) and self-administered products when the patients are competent to use the factors without medical supervision. Medicare covers blood-clotting factors for the following conditions: Factor VIII deficiency (classic hemophilia, hemophilia A). Fact...2021-05-1710 minPharmacy Revenue Cycle PodcastDid you mean to say EAPG?EAPG or the Enhanced Ambulatory Patient Grouping is among the models focused on transitioning fee for service to a value based payment. Over 25% of the state Medicaid programs in addition to several commercial payers have adopted the EAPG outpatient prospective payment system. 3M developed the methodology to provide greater uniformity in payments across multiple diverse outpatient areas and designed to represent all patients, not just Medicare. There are 8 EAPG types that are assigned to each claim line to classify the services in a visit. The classification or logic is based on the presence of an A...2021-05-1205 minPharmacy Revenue Cycle PodcastOff-label Use and ReimbursementWhen the Food and Drug Administration (FDA) approves a drug for sale in the United States, the approval includes a section entitled “Indications for Use.” This section lists the one or more diseases, conditions, or symptoms for which the drug’s sponsor (usually the manufacturer) has provided, to FDA’s satisfaction, evidence in support of the drug’s safety and effectiveness. Prescribing for these parameters is considered “on-label” or “labelled” uses. The FDA traditionally has not regulated the practice of medicine and therefore physicians may prescribe an FDA-approved drug for indications not listed in the official FDA-approved labels. This is co...2021-05-0404 minPharmacy Revenue Cycle PodcasttPA-Drip anTime is Money - Diving into the details of “Pass-Through Status”Drugs continue to enter the market at a fast rate with a heavy price tag. This is complimented with lightning speed information flow directly to providers and patients creating a quick uptake in the utilization. “Time is money”. This phrase has stood the test of time and is more important to consider in the evaluation of the pharmacy revenue cycle. CMS provides temporary or transitional pass-through payment for certain drugs, biologicals and radiopharmaceuticals as indicated in the Social Security Act Section 1833(t)(6). For the purposes of pass-through, radiopharmaceuticals are included as “drugs”. The follo...2021-04-2604 minPharmacy Revenue Cycle PodcasttPA-Drip and Ship-Additional Reimbursement for Receiving FacilitiesAn important element in the American Heart Association’s, “Get with the Guidelines-Stroke“ is that tPA should be administered within 4.5 hours of the first sign of stroke to dissolve the blood clot, restore blood flow to the impacted area of the brain and reduce disability. “Drip and ship” means that front-line, community hospitals quickly administer tPA to people suffering an ischemic stroke, and then immediately transport them to a comprehensive stroke center. The front-line community hospital typically treats the patient in the Emergency Department, administers tPA and prepares the patient for transport. T...2021-04-1904 minPharmacy Revenue Cycle PodcastCAR T-cell Therapy: Coverage and Billing for OutpatientsChimeric Antigen Receptor (CAR) T-cell therapy is an example of a rapidly emerging immunotherapy approach called adoptive cell transfer (ACT) where patients’ own immune cells are collected and used to treat their cancer. This newsletter details coverage and billing instructions when the products are used on an outpatient basis. A future newsletter will provide instructions when used for an inpatient. The Center for Biologics Evaluation and Research (CBER) of the Food and Drug Administration (FDA) regulates cellular therapy products, human gene therapy products, and certain devices related to cell and gene therapy. The FDA p...2021-04-1205 minPharmacy Revenue Cycle PodcastOn the Hunt, with TPEAs Easter Eggs are hunted this weekend, CMS has picked back up their auditing services which were previously slowed due to Covid. The Targeted Probe and Educate (TPE) program is a way to help you as an organization identify errors and provide one on one help to correct them. The TP&E specifically targets providers or suppliers who have high error claim rates or unusual billing practices and items and services that have high national error rates and are a financial risk to Medicare. Medicare Administrative Contractors (MAC) focus only on providers/suppliers that have been identified as potential...2021-04-0504 minPharmacy Revenue Cycle PodcastBack to the Future: Restated Drug and Biological Payment Rates Each quarter, CMS recalculates the payment rates for drugs based upon data electronically submitted by the manufacturers. Occasionally a manufacturer reports an average sales price (ASP) incorrectly, or CMS makes an error in blending multiple manufacturer submissions. However when audits occur, or providers request a recalculation, CMS will “restate” payment rates for both hospital outpatient departments and ambulatory surgery centers. These are posted each quarterly at the following CMS Locations: OPPS restated payment rates ASC restated payment rates So, what do we do with these tables? In general, there are u...2021-03-2903 minPharmacy Revenue Cycle PodcastDon't Let Your Revenue Decay For RadiopharmaceuticalsAdvancements in cancer therapy continue to emerge and among those options are radiopharmaceuticals. Radiation therapy has been around for centuries, but radiopharmaceuticals are relatively new, with iodine-131 being the first radiopharmaceutical to be approved by the FDA in 1951. Today, there are several new therapeutic radiolabeled compounds and isotopes that are causing organizations to pause to ensure charge capture and billing is appropriately addressed due to the increase in usage and cost of these agents. CMS addresses radiopharmaceuticals alongside other drugs and biologicals. Medicare Claims Processing Manual 90.2 directs hospitals to report charges for all drugs, biologicals and...2021-03-2204 minPharmacy Revenue Cycle PodcastMarch Madness: Double your money for COVID-19 vaccine administration CMS has increased the Medicare payment for administering the COVID-19 vaccine for doses given on or after March 15, 2021. The national average payment rates for physicians, hospitals, and pharmacies is now $40 to administer each vaccine resulting in $40.00 for single dose vaccines, and $80.00 for vaccines requiring two doses. (This is an increase from previous payment rates of $28.39 for single dose vaccines and $45.33 for two dose vaccines). Note: all rates are geographically adjusted. For currently authorized vaccines, the following CPT codes should be used to bill for the administration. As the product itself is sti...2021-03-1605 minPharmacy Revenue Cycle PodcastAdding a Layer to the Onion - Route of Administration Modifiers Billing modifiers are typically two characters composed of either letter or numbers, and a CMS Form-1450 or UB-04 can accommodate up to four modifiers on each CPT (Level I HCPCS) or Level II HCPCS. Modifiers are designed to provide the payer with more specificity about the service rendered, improve accuracy of coding, used to overcome edits (e.g. NCCI) or drive payment. Route of administration modifiers are not new to billing and coding. While some MACs recognized the route of administration modifiers, reporting them on the claim was voluntary. However, we are seeing individual MACs n...2021-03-0904 minPharmacy Revenue Cycle PodcastBilling for Pharmacists’ Services provided in a Hospital Outpatient DepartmentCMS recently provided instructions on how pharmacists services provided in a physician office are billed on a 837P (electronic)/CMS-1500 claim form in the 2021 Physician Fee Schedule Rule published in the Federal Register on December 28, 2020. (See our newsletter of February 8, 2021). However, there is no written guidance (CMS Rule or Transmittal) specifically addressing how pharmacists’ services provided in a hospital outpatient department should be billed. We’ve received a number of questions particularly involving the billing of anticoagulation monitoring services on a 837I/CMS-1450 claim form when these services are provided as a hospit...2021-03-0110 minPharmacy Revenue Cycle PodcastWhat could go wrong? Dealing with an 'invalid NDC' charge rejectionWe are hearing from more health-systems that they are receiving an increasing number of charges rejected for an “invalid NDC number”. How can this be? Let’s walk through some history and then look at the most common reasons for the denial. History: State Medicaid programs began requiring National Drug Code (NDC) numbers on outpatient claims in 2006 based upon a federal mandate from the Deficit Reduction Act of 2005. CMS provided instructions to the States with full implementation by 2008. The purpose was so that State Medicaid programs could include physician-administered drugs from physician offices and hospital outpati...2021-02-2210 minPharmacy Revenue Cycle PodcastDon’t be “SAD”... An Alternative Way to Handle Self-Administered DrugsSelf-administered drugs (SAD) have been a long-standing controversy when administered in a hospital outpatient setting from the perspectives of a patient, frontline healthcare workers, and billing. “Why does my Tylenol cost $10 per tablet, but the 1,000 count bottle I have at home was purchased for $3?” This question is often difficult to answer and may lead to unintended operational consequences. SAD is defined as medication that is usually administered by the patient. “Administered” refers to the physical process in which the drug enters the body. Oral, topical, suppositories, and others are typically considered medications that can be self admini...2021-02-1507 minPharmacy Revenue Cycle PodcastBilling for Pharmacists’ Services provided in a Physician OfficeThe Physician Fee Schedule (PFS) Final Rule was published in the Federal Register on December 28, 2020 and includes instructions on the billing of services provided by pharmacists “incident to” physicians’ services when provided in the physician office setting (Place of Service Code=11). These services are billed by the physician on a 837P or CMS-1500 claim form. The rule includes the following clarifications: Medication management is covered under both Medicare Part B and Part D. When the services are provided and paid under the Part D benefit, the services are not also reportable or paid for und...2021-02-0807 minPharmacy Revenue Cycle PodcastIt’s Groundhog Time Again… C9399 and Drug Billing with Waste Again…In a previous newsletter, we addressed the efforts surrounding billing for drug waste and the importance of applying the JW modifier. Separately, we discussed the importance of billing a FDA approved drug with a C9399 that has not been assigned a permanent HCPCS. Though it seems intuitive to apply the waste billing logic to a drug coded with C9399, most EMRs are unable to perform this cleanly and may leave you with an area of revenue leakage. First, let us review the elements required to bill for C9399 and drug waste. ✅ HCPCS code C9399...2021-02-0304 minPharmacy Revenue Cycle PodcastCome One, Come All for the Covid-19 VaccineIn addition to back-to-back winter storms predicted for this week in Washington, D.C., President Biden issued a Memorandum on January 20, 2021 for the Heads of Executive Departments and Agencies: “Regulatory Freeze Pending Review.” In this document, President Biden has directed Agency Directors to “pause” the implementation of pending regulations (unless emergency situations exist) to allow President Biden’s appointees to review and approve the rules. This regulatory “freeze” applies to two rules’ statuses: 1) those regulations that have been sent to the Office of the Federal Register (OFR) but have not yet been published, and 2) those regulations that h...2021-01-2505 minPharmacy Revenue Cycle PodcastCome One, Come All for the Covid-19 VaccineBy now many of you have mobilized operations to begin the initial phases of vaccinating for Covid-19, but it doesn’t stop there. Operations are continually evolving invoking new challenges daily (if not hourly). Billing for the Covid-19 vaccines has also presented some unique obstacles to overcome. The Coronavirus Aid, Relief and Economic Security (CARES) Act outlines several of these requirements. Billed Claim When the vaccines are provided free of charge, the vaccine product code should NOT be included on the claim. Only the administration codes should be reflected on the claims. Note, this...2021-01-1804 minPharmacy Revenue Cycle PodcastMFN Model Rule under Temporary Restraining Order (TRO)The National Uniform Billing Committee (NUBC) has announced two new condition codes to be reported on CMS-1450 (UB-04)/837I (Institutional) claims effective February 1, 2021 that impact drug products. Condition Code 90- Expanded Access Approval (Service provided as part of an Expanded Access Approval) Condition Code 91- Emergency Use Authorization (Service provided as part of an Emergency Use Authorization. Condition codes are added to institutional claims to identify events relating to billing that may affect processing. The current UB-04 (837I) claim has 11 fields for condition codes. They are 2-character alphanumeric fields and are r...2021-01-1305 minPharmacy Revenue Cycle PodcastMFN Model Rule under Temporary Restraining Order (TRO)As we all ring in the New Year, let’s make the Pharmacy Revenue Cycle a priority for the New Year. This letter brings you a compilation of the top information to set your Pharmacy Revenue Cycle information on the right foot with updates on the MFN Model Interim Final Rule, CY2021 OPPS Final Rule and updated tools for C9399 and Hemophilia Factor reporting. Most Favored Nation (MFN) Update On December 28, 2020, the US District Court for the Northern District of California issued a preliminary injunction that will prevent implementation of the MFN Payment Mode...2021-01-0405 minPharmacy Revenue Cycle PodcastMFN Model Rule under Temporary Restraining Order (TRO)According to news reports from Reuters and Modern Healthcare (subscriber only content), a judge in Maryland has issued a temporary restraining order (TRO) for 14 days (which will expire January 6th) to prevent CMS from implementing the Most Favored Nation (MFN) Model Rule on January 1, 2021. The restraining order was on the basis that CMS did not give adequate notice as required under the Administrative Procedures Act and that there is the potential for irreparable harm. The TRO can be extended again, a hearing can be held during the order, or the TRO can expire. A reader has asked, “Wha...2020-12-2804 minPharmacy Revenue Cycle PodcastA Christmas Present-Will the MFN rates increase or decrease your drug revenue?CMS has posted the Most Favored Nation (MFN) Model final payment rates on the Innovation Center website here: January 2021 MFN Model Drug Pricing File (XLS). The drugs will be reimbursed based upon 75% of the applicable ASP and 25% of the MFN price for which MFN pricing was available. Otherwise the payments rates are 100% of ASP. Column D contains the MFN Drug Payment Amount Limit. This payment will continue to be subject to Medicare co-pays and deductibles, however the payment rate for M1145 will not as Medicare will reimburse the full amount to providers with no co-pays or...2020-12-2105 minPharmacy Revenue Cycle PodcastQuestions on the Most Favored Nation (MFN) Model RuleWe’ve had another great question this week about the “Most Favored Nation” Model Rule and billing the new HCPCS code, M1145- MFN drug, add-on payment. Question: How would you suggest establishing the M1145 charge in the charge router in order to ensure billing compliance across all financial classes? Answer: We agree that there are a number of factors that contribute to this decision and it is a gray area in the Interim Final Rule. Without additional guidance from CMS or other payers, we recommend billing M1145 on all patients regardless of payer or...2020-12-1411 minPharmacy Revenue Cycle PodcastQuestions on the Most Favored Nation (MFN) Model Rule Thank you for continuing to read our newsletters and submit comments and questions! We have heard several questions related to our previous newsletter regarding the recently issued rule by CMS impacting Part B medication payments, Most Favored Nation (MFN). Today’s edition is geared toward answering your questions! Please reference last week's newsletter for an overview of the MFN rule: Black Friday Price Drop!!!-For Drug Payments?? What is the add on payment for the new MFN drugs? CMS has published the HCPCS M1145 - MFN drug add-on, per dose. This cod...2020-12-0810 minPharmacy Revenue Cycle PodcastBlack Friday Price Drop!!!- for Drug Payments??Does 2020 have more surprises for us? Well, CMS released an Interim Final Rule published in the November 27, 2020 issue of the Federal Register that will potentially decrease payment for fifty expensive drugs provided in hospital outpatient departments and physician offices starting January 1, 2021 (“Most Favored Nation (MFN) Model”). Although a similar advance notice of proposed rulemaking (ANPRM) (83 FR 54546) was issued in October 2018, this Final Rule has significant logistical differences from the original proposal, including specific instructions on claims billing. What We Know Who is impacted? 1. All beneficiaries enrolled in Medicare Part B who have...2020-11-3009 minPharmacy Revenue Cycle PodcastCovid-19 Monoclonal Antibody - Can you say Bamlanivimab 10 times fast?Likely, you just heard of Bamlanivimab, and like wildfire it is being repeated in meeting after meeting within your organization. On November 9th, the FDA issued an emergency use authorization (EUA) for the investigational monoclonal antibody therapy, bamlanivimab for the treatment of mild-to-moderate COVID-19 patients. The monoclonal antibody is expected to be distributed within the next week. Unlike the investigational therapies before it, this infusion will target your outpatient sites of care and add a layer of complexity with billing in which we have outlined. Bamlanivimab EUA is extended to patients with a positive SARS-CoV-2 test, >12 years...2020-11-1605 minPharmacy Revenue Cycle PodcastDon’t Let Rabies Take a Bite Out of Your RevenueSeems like a slam dunk, doesn’t it? A patient comes to the Emergency Department with an animal bite. A standard CDC protocol for rabies post-exposure prophylaxis (PEP) outlines initial therapy with both rabies immune globulin and rabies vaccine, with additional vaccine on Days 3, 7, and 14. An 5th dose of vaccine may be needed on Day 28 if the patient is immunocompromised. What can possibly go wrong with the reimbursement? Well apparently a lot, since we see many write-offs, mostly for visits when the patient returns to the Emergency Department for their subsequent vaccine doses. The...2020-11-0906 minPharmacy Revenue Cycle PodcastRemdesivir added to C9399 ToolIn this Special Bulletin of Pharmacy Revenue Cycle News, we are answering questions sent to us from Michael from a health-system in Indiana. Michael writes, “When do you use HCPCS code C9399 versus J3490 for unclassified drugs?” Response: We recommend using C9399 instead of J3490 or J3590 because the C9399 code has an OPPS status indicator of “A” and is reimbursed for outpatients at 95% of AWP. The J3490 and J3590 codes have a status indicator of “N” meaning they are covered but you won't receive any separate payment. So you definitely want to use C9399 when the drug...2020-11-0203 minPharmacy Revenue Cycle PodcastMedically Unlikely Edits (MUE)Medically unlikely edits or MUE are designed to help reduce the number of billing errors, but have the potential to create obstacles within the pharmacy revenue cycle. The National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services was developed to encourage consistent and correct coding thereby reducing inappropriate payments. The NCCI Policy Manual for Medicare Services contains 13 narrative chapters in which chapter XII which addresses HCPCS Level II codes and MUE. Each quarter the NCCI is updated to reflect changes from 3 sources 1) additions, deletions, or modifications in the CPT manual or HCPCS 2) CMS policy ini...2020-10-2605 minPharmacy Revenue Cycle PodcastWhat’s New? Using HCPCS Code C9399HCPCS code C9399-Unclassified drugs or biologicals, can be used to bill for new drugs, biologicals, and therapeutic radiopharmaceuticals that are approved by the FDA on or after January 1, 2004 when a product-specific HCPCS code has not yet been assigned when furnished in hospital outpatient departments. (Medicare Claims Processing Manual, pg 63). This C9399 tool includes the generic and brand names, approval dates, manufacturer, and a link to the prescribing information (PI) for injectable drugs that have been approved by the FDA but have not been assigned a HCPCS code by CMS. This list will be updated each quarter...2020-10-1905 minPharmacy Revenue Cycle PodcastLet’s Talk About Billing Drug WasteHave you ever questioned... “Is charging for waste worth the effort?” “Am I required to charge for drug waste?” “My organization states we have been charging for waste for over a decade, what is all the hoopla for now?” Billing for the waste of drugs and biologicals has been embedded in the CMS manuals for many years. CMS has always encouraged providers to administer drugs in a manner that minimizes waste when clinically appropriate. For example, providers may consider scheduling patients in a way that allows multiple patient doses prepared from the same via...2020-10-1207 minPharmacy Revenue Cycle PodcastOctober 2020 Quarterly code updatesThis edition of Pharmacy Revenue Cycle News is a compilation of all quarterly resource files that detail code changes pertinent to drug billing effective October 1, 2020. Here’s a listing of the files and a short description of what each one contains. We recommend that pharmacy, finance, and revenue integrity review all files for changes pertinent to drugs in use at the facility, and update their IT systems to reflect the current information. We have three shoutouts; two pertain to reviewing previous claims for potential rebilling, and also an evaluation of formulary status for drugs with status indicator changes regarding se...2020-10-0506 minPharmacy Revenue Cycle PodcastTRICARE NTAP and Investigational Drugs related to COVID-19The Department of Defense published an Interim Final Rule in the Federal Register on September 3, 2020 with two provisions which directly impact payment for drugs on TRICARE inpatient and outpatient claims. The first provision is that TRICARE will adopt the payment criteria and formulas for new technology add-on payments (NTAP) as outlined in CMS Inpatient Prospective Payment System (IPPS) Final Rule. This is a new payment provision and will be made retroactive to January 1, 2020. In the future, TRICARE will adopt CMS’s effective date of October 1 of each year. This is listed as a permanent change. For a too...2020-09-2804 minPharmacy Revenue Cycle PodcastNew Technology Add-on Payments (NTAP)Question: “Don’t all inpatient claims receive the same fixed payment based upon the diagnosis? Why should I itemize charges on an inpatient?” Answer: “YES; you should itemize because you may receive extra reimbursement in addition to the MS-DRG payment.” One scenario that generates extra payment is when services, (including drugs) are used on inpatients that are designated for New Technology Add-on Payments (NTAP). Next question: “What do I need to do to receive the extra payment?” •The medical record must contain a valid order for the drug, •The medical record must contain documentation of the administration of at least one dose, and, •The...2020-09-2106 minPharmacy Revenue Cycle PodcastInfluenza VaccineHealthcare organizations are being asked to manage ventilators, drug shortages, establish telehealth services, manage a budget, and downsize staff among other tasks amid the pandemic. You may leave the day feeling as if you were Thor conquering the Nine Realms. The Pharmacy Revenue Cycle Newsletter aims to put the Mjölnir (hammer of Thor) into your hands and provide you with helpful tips, resources, and emerging updates that can improve your pharmacy revenue. “Pharmacy Revenue Cycle” (www.pharmacyrevenuecycle.com) is brought to you by Agatha Nolen, Ph.D., CRCR, FASHP and Maxie Friemel, PharmD, MS, BCPS, CRCR. Together we bring over 2...2020-09-1205 min